I missed this when it came out, but it is well worth considering. About a year ago an abortion doctor explained why she believes abortion is a positive good, and why, despite knowing that babies she aborts are both healthy and viable she feels no compunction about using a vacuum to kill them and suck them out of a womb.

It is a disturbing glimpse into the mind of a person conscious that she is killing a human being and simply not caring. If you want to understand the culture of death, you should understand the thinking of those behind it.

Before I go further let me stipulate one thing: most people who support abortion in America do not think like this. They believe sincerely, rightly or wrongly, that prior to some point in the pregnancy the fetus in the womb is not human in any important way. Biologically they have human DNA and organs, but they are not conscious of their existence and are mindless non-persons. They do not support killing people, but human flesh alone.

This is, for many, a moral gray area. Abortion though of this way is similar to pulling the life support from a person with brain death. Distasteful, but not immoral. That is why the courts established viability as a marker beyond which abortion regulation is permitted, at least until the Congress changes (perhaps unconstitutionally) the law. Viability is not the same as brain development, but it is a proxy.

None of this matters to Christine Henneberg, an abortion provider in California. For her the fetus/baby is irrelevant to the moral equation.

In fact she makes quite clear at the beginning of her essay that she will show more compassion to worms than to a human fetus. Inflicting pain on a worm horrifies her; using a vacuum to kill a perfectly formed fetus able to feel pain does not. She literally values worms more highly than people.

When I was a pre-med biology student, our professor gave us a lab assignment that involved pinning an earthworm to a small piece of wood, then probing it with an electrode to observe its response. The lab was intended to show us a primitive nervous system at work. (The question of whether earthworms feel pain is a gray area in invertebrate physiology—or it was at the time.)

I followed the instructions and flicked at one end of my earthworm. It writhed and squirmed; I drew my hand back. Whatever the earthworm was experiencing, it looked like pain to me. After a few more tries, I asked the professor to excuse me from the rest of the assignment, explaining that I couldn’t bear to torture a living creature.

Christine is exquisitely sensitive to and compassionate for the pain of worms. This strikes me as extreme, but easily morally justifiable. We all have limits to our ability to feel compassion, but it is not bizarre to draw the line here. At least not to me. My compassion does not extend as far, but it extends far lower down the consciousness chain that human beings.

Yet Christine’s compassion for worms does not extend to a a perfectly formed fetus; one that she clearly believes is a person with value. That value, though, is not inherent to the person, but to others. Human worth is determined by the values that others place on us. Perhaps because there is no God to bestow an inherent value?

On a recent afternoon in my clinic, fifteen years after the earthworm experiment, a young medical assistant named Jenny approaches me between patients. “Can I show you something?”

She pulls up an ultrasound video on her phone: a fetus, its perfectly formed limbs, fingers and toes, squirming and jumping in its wedge-shaped sonographic window, bounded by the fuzzy, white-gray walls of a uterus.

“Awwww! Adorable!” I look at Jenny; she is beaming. I have known for some time that she is pregnant. (She occasionally asked for my advice during the eight months it took her to conceive.) “How many weeks are you now?” I ask her.

“Fifteen.”

“Fifteen weeks! Wow! Look at that little baby. So cute!” It wasn’t long ago that I was pregnant with my own children, gazing lovingly at their ultrasound photos.

“Look at that little baby. So cute.” Clearly this is a person, already loved. It is perfect, and squirms and jumps within the womb.

Soon after this conversation Christine and the nurse enter a surgical room to kill a fetus at exactly the same stage of development without a qualm. A perfectly healthy–to use her word, not mine–baby.

Later that afternoon, Jenny assists me during a fifteen-week procedure. The fetus on the ultrasound screen looks just like Jenny’s, in every recognizable, perfectly formed detail: fingers, toes, beating heart. But this image is very different because of the context in which I am viewing it.

The woman is lying on the table, awake but sedated by medications. I dilate her cervix and place a small plastic tube inside her uterus. I watch the ultrasound screen. I flip a switch; a humming noise fills the room. At this instant, the fetus seems to jump as though startled; then it squirms in the tight, already shrinking space of the uterus. It continues to move in this very human, baby-like way until the last instant, when it is overpowered by the force of the vacuum and sucked through a plastic tube, whisked out of the uterus and into a glass jar in a rush of blood. Gone.

Then all I see on the ultrasound is the fluffy, whitish-gray lining of the uterine walls; after a few more seconds, even that disappears. All that is left is the empty uterus, and the memory—mine and Jenny’s alone—of what was there before.

This, I suppose, is precisely the kind of test my pre-med classmate thought I had failed: a test of my strength to do what is asked of me, to handle the most difficult, even painful moments. How wrong she was. And how wrong, how ill-informed, was the very premise of that test. My willingness—I would call it a conscientious compulsion—to perform abortions has nothing to do with toughness or timidity.

Most people would shrink from describing any of it, especially the gory details. Hennenberg does not because she believes she is morally compelled to commit such acts, and it is that which requires our consideration.

How? Why? Are you not admitting to being a monster? A person who commits murder on a routine basis?

Condemnation–our first impulse, or at least mine and many others–does no good. This is legal, even lavishly praised. The right to do precisely this has been enshrined both into law and into some state constitutions, and is likely to be expanded around the country. We simply must understand the thinking of such people.

Many can claim ignorance of the details and shrink from learning them. But those who knowingly kill beings they know to be human beings must be explained. Psychopathy is not the explanation; so what is?

If fetal viability—or, for that matter, a fetal heartbeat—isn’t an acceptable standard for thinking about abortion, then what is? For me the standard is what I call the woman’s contextualized autonomy.

I distinguish this term from a simple notion of autonomy that ignores the constraints women face in an unequal and unjust society. Rather, I mean to invoke a more expansive and just notion of autonomy that is synergistic with the goal of bodily autonomy outlined by the Reproductive Justice Movement. This autonomy includes a woman’s control over her body, but it also acknowledges the ways in which her own decisions about her body impact her family and her children.

At its heart, contextualized autonomy flows from equality. It centers the woman’s experiences. It rejects a paternalistic view (recently and strategically popularized by the anti-abortion movement) of the woman as passive and childlike, requiring the state’s protection against predatory abortion doctors who would trick her into killing her baby. Instead it demands an unrelenting trust from society at large (including her physician) in the woman’s ability to make her own decisions about her life, her goals for her future and for the futures of children, even in the face of difficulty, complexity, and constraint.

Hennenberg, and millions of others in the pro-choice movement, actually do draw the line at “choice.” Which, if you consider the matter, means simply that the moral value of a human being comes down to something as simple as being wanted and valued.

You are not a human being with rights and inherent worth; worth and rights are entirely determined by the choices of others. To live is to be a chosen one, not by God, but by human beings.

This is where it gets even more difficult: If the woman’s contextual autonomy is the standard, then we come to the question of unrestricted abortion. Is this what I am proposing? Am I suggesting, in the words of Donald Trump in the 2016 presidential debates, that abortion be legally available “in the ninth month” or “just prior to the birth of the baby?”

Yes and no. Again, context matters.

Yes, my value of the woman’s bodily autonomy above all else leads me to believe that women should have access to legal post-viability abortion. This is (for the time being) within the realm of constitutional law. Roe doesn’t explicitly ban abortion after viability; it only permits states to regulate or “go so far as to proscribe abortion during that period.” A handful of states do permit abortion in the third trimester. (When I meet a patient who is past the point of viability seeking abortion in my state of California, I refer her to a clinic in New Mexico.)

A post viable abortion is no small matter. It goes far beyond the evil of sucking a baby out of the womb. It requires an actual birth to take place. A birth that could and would result in a live baby should it be allowed to survive. There are even some survivors of such abortions, although they are very rare because medical professionals whisk away these live babies to die alone in dark rooms.

These days the doctors usually kill the baby with drugs in the womb prior to delivery in order to ensure that they are not breaking a law, but the reality remains that late term abortions require childbirth, including all the risks associated with it. The “life of the mother” argument is actually moot in many of these cases.

A late second-trimester abortion (between roughly sixteen to twenty-four weeks of gestation) is performed as a procedure called a Dilation and Evacuation—in which the fetus, too large to fit through a plastic tube, is removed in parts through the woman’s cervix with the use of surgical forceps. This is the fastest and safest way to get the fetus out of the woman’s body. It is also the only legal way. The “Partial Birth Abortion Ban” of 2003, ostensibly enacted to protect the fetus from the (theoretical) pain of suffocation and death, makes it a crime for a physician to intentionally remove an intact, live fetus from a woman’s uterus.

After twenty-four weeks, however, when the fetus and uterus have grown substantially larger (in the third trimester, the uterus circulates approximately one-third of the woman’s entire blood supply), the removal of the fetus in parts becomes less safe and effective than the alternative: inducing labor. Such inductions are accomplished with the same medications used on Labor & Delivery wards to induce live births. The major difference is that, in large part because of the Partial Birth Abortion Ban, the doctor first ensures intrauterine fetal death by injecting a medication that stops the fetal heart, usually very quickly.

After that the induction looks much like any other delivery. The woman’s uterus begins to contract. She feels pain, which doctors try to ease with medications, comfort measures, and soothing words. After minutes or hours, a small, still fetus emerges from the woman’s vaginal canal and into the doctor’s hands. The placenta follows. The woman may see and hold the baby, or she may choose not to. Her bleeding is monitored and controlled. Sometimes she requires stitches. She always requires some recovery, both physical and emotional. She has just delivered a baby—or a fetus. What we decide to call it, and whether it is viable or non-viable, are entirely beside the point.

This is the crux of the argument: the death of a child, living but not yet breathing solely due to the choice of the mother and doctor to kill it, is only acceptable if you believe that human worth is entirely determined by the choices of others. And those choices can take place at any time. Because in most cases–by far the vast majority–the women choosing to have the baby explicitly or implicitly chose to become pregnant. Either through intention or neglect, as there are ample means to prevent pregnancy, up to and including Plan B for accidental insemination.

An abortion at 20 or 24 or 28 or 30 weeks cannot be understood as a quick decision to stop an unwanted pregnancy. It is a choice to kill a child. And to be clear, nobody disputes that saving the life of the mother is an adequate reason to prevent carrying a child to term. This argument put forth by Hennenberg and abortion until birth advocates is aimed at killing healthy children, as she herself describes them.

Hennenberg and her ilk neither dispute nor care that the people being killed are actually children.

They simply deny a person has value until somebody values it. And if the person is not valued it is fine to kill them, even through torturous means. Means that one would not, in fact, inflict on a worm.

This may seem to many of us as psychopathic, but it is the moral framework that guides many, perhaps most of the moral arbiters in our society. These are our overclass. We must see them for who they are. Their disagreement with the moral sense of most people is not over when life begins, but over the very meaning of life.

And if the inconvenient child has no inherent worth: do you? When you choose to go down this path, you are putting everybody’s life in the hands of the powers-that-be.